Colostomy
Definition:-
Surgical creation of an opening i.e. stoma between the colon and the abdominal wall to allow faecal elimination.
Types of colostomy:-
Temporary
Permanent
Temporary
If the colostomy is done
1. To relieve and obstruction which can be corrected by the resection of the bowel
2. To divert the faecal stream to permit healing of a portion of the bowel
it is called temporary colostomy.
Permanent
Permanent colostomy is usually performed in conjunction with an abdomino perineal resection. After the sigmoid colon is resected the proximal end is brought out through abdominal wall and sutured to it to form a permanent opening for the elimination of faeces.
Indications
1. Rectal cancer
2. inflammatory bowel disease
3. trauma
4. ischaemic bowel
5. congenital conditions
Preoperative managemant
prepare the patient for general abdominal surgery
administer replaement fluid as ordered before surgery
provide low residue diet before nil by mouth status
explain that the abdomen will be marked by the ostomy speciality nurse or surgeon to ensure proper positioning of stoma.
Considerations when selecting a stoma include
a. positioning within rectus muscle
b. avoidance of bony prominences such as iliac crest and costal margin
c. clearance from umbilicus, scars, and deep creases obsered in lying, sitting and standing . . .. positions
d. positioning on a flat pouching surface
e. avoidance of beltline when possible
f. positioning within patient's visibility to optimize independent ostomy care.
g. Support the patient and family with the many psychosocial considerations of ostomy surgery.
Post operative management
1. administer general abdominal surgery care
2. assess stoma every shift for colour and record findings
a. normal colour : pink -red
b. dusky ; dark red, purplish hue (ischaemic sign)
c. necrotic : brown or black may be dry ( notify health care provider to determine extent of necrosis)
3. apply pouching system with ˝ inch clearance to prevent stomal constriction, which contributes to oedema.
4. check for abdominal distension, which recuces blood flow to stoma through mesenteric tension
5. evaluate and empty drains and colostomy pouch frequently to promote patency and maintain seal
6. monitor intake and output with extreme accuracy because output may remain high during early post operative period.
7. suction and irrigate NG tube frequently, as ordered to relieve pressure and decrease gastric contents.
8. offer continued support to patient and family
colostomy care
Equipment
1) irrigator bag or enema bag
2) irrigating fluid : 500 - 1500 ml lukeworm water or othe solution prescribed
3) irrigating tip one tip or soft rubber catheter 22 or 24 with shield to prevent backflow of irrigating sloution
4) irrigating sleeve: long large - capacity bag with opening at top to insert cone or catheter into stoma
5) large tail closure
6) water soluble lubricant
Procedure
Preparatory phase
1. explain the details of the procedure to the patient
2. answer any questions
3. select a consistent time free from distractions. If the patient is learning to irrigate for bowel control choose thetime of the time of day that will best fit into the patient's life style.
4. have the patient sit in front of the commode on a chair or on the commode itself, providing privacy and comfort.
5. hang tehirrigating reservoir with prescribed solutions so that the bottom of the reservoir is approximately at the level of the patient's shoulder and above the stoma
performance phase
1) Remove tubing clamp on the irrigating reservoir to release a small amount of solution into the commode.
2) Open tubing clamp on the irrigating reservoir to release a small amount of solution into the commode
3) Lubricate the tip of the cone shield gently but firmly against stoma to prevvent backflow of water
4) If catheter does not advance easily, allow wate to flow slowly while advancing catheter. Never force catheter. Dilating the stoma with lubricated gloved finger may be necessary to direct cone/catheter properly.
5) Allow water to enter colon slowly over a 5-10 mts. Continue period. If cramping occurs slow the flow rate or clamp tubing to allow cramping to subside. If clamping doesn't subside remove cone/ catheter to release contents.
6) Hold cone/shield in place for 10 second after water is instilled, then gently remove cone/catheter from stoma.
7) As faeces and water flow down sleeve periodically rinse the sleeve with water allow 10 - 15 minutes for most of the returns then dry sleeve tail and apply tail closure
8) Leave sleeve in place for approximately 20 more minuteswhile patient gets up and moves around.
9) When returns are complete, clean stomal area with mild soap and water pat it dry, reapply pouch or covering over stoma.
Follow up phase
a. clean equipment with soap and water; dry and store in well ventilated area
b. wherever applicable, the patient should use a pouch until the colostomy is sufficiently controlled
Complications
1. mucocutaneous separation (between skin and stoma)
2. stomal ischaemia
3. stomal stricture or stenosis
4. stomal prolapse
5. peristomal hernia
6. peristomal skin brekdown from exposure to faecal output allergic reaction to products, or infection, such as candidiasis
Additional information
With a colostomy or ileostomy, a special bag is attached to the site that collects the faeces. The opening on the abdominal wall must be well cared for because bowel contents can irritate the skin, which results in ulceration and infection. Unlike at the anus, no mechanisms are in place to regulate the flow of faeces. The use of appliances such as a bag-and-seal over and around the stoma can, in turn, cause damage to the skin from their frequent removal, and from allergy to the materials used.
What necessitates a stoma and who is at risk?
Stomas are commonly necessary in sufferers of inflammatory bowel disease, including Crohn's disease and ulcerative colitis. They are also formed during operations for bowel cancer, diverticular disease and after accidental damage to the bowel wall.
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Stoma care
What is a stoma?
A stoma is an artificial opening to or from the intestine (which is also known as the gut or bowel) on the abdominal wall usually created by a surgeon. Occasionally, it is an artificial opening in the urinary tract, called a urostomy.
When is a stoma required?
A stoma is necessary when parts of the normal intestine must be bypassed, for example when bowel surgery has removed important lengths of the intestine, or when food cannot be taken in by mouth. The main different types of stoma depend on the part of the intestine that forms the opening:
" gastrostomy, an opening from the skin directly into the stomach, to allow feeding,
" jejunostomy, an opening from the first part of the small bowel, also used for feeding,
" ileostomy, an opening from the small bowel, to allow faeces to leave the body without passing through the large bowel,
" colostomy, an opening from the large bowel, to allow faeces to bypass the anus.
Another type of stoma, called a urostomy, is an artificial connection between the urinary tract (the kidneys, bladder and tubes that connect them) and the abdominal wall, sometimes referred to as a 'urinary conduit'.
Stomas may be temporary (to allow another part of the intestine to heal), or permanent. If they are temporary another operation is required to close them.
Stomas are carefully sited on the abdominal wall so that they can be hidden and yet still function. With a colostomy or ileostomy, a special bag is attached to the site that collects the faeces. The opening on the abdominal wall must be well cared for because bowel contents can irritate the skin, which results in ulceration and infection. Unlike at the anus, no mechanisms are in place to regulate the flow of faeces. The use of appliances such as a bag-and-seal over and around the stoma can, in turn, cause damage to the skin from their frequent removal, and from allergy to the materials used.
What necessitates a stoma and who is at risk?
Stomas are commonly necessary in sufferers of inflammatory bowel disease, including Crohn's disease and ulcerative colitis. They are also formed during operations for bowel cancer, diverticular disease and after accidental damage to the bowel wall.
Urostomies are not common and are performed if there is a problem that prevents urine produced by the kidneys from reaching the outside of the body. Such problems can arise because of cancer, or pelvic or abdominal surgery.
What are the common symptoms and complications of having a stoma?
The problems of a stoma can often be psychological, and the patient may be initially shocked by the appearance of the patientr stoma. The patient may experience a 'phantom rectum' with the urge to defecate (empty the bowels) for several days or weeks after formation of the stoma. The patientr body image may be affected, and the patient will need the support and understanding of the patientr family and friends, and the professionals that care for the patient, to help the patient through this time and to minimise any effects on the patientr quality of life.
Once the initial decision to form a stoma has been reached, the patient will be introduced to a specialist stoma nurse who can explain the implications for everyday life. The nurse can show the patient the different type of appliances available, how they should be used and how to acquire them. A stoma nurse can also put the patient in contact with support groups and other people who have stomas, for reassurance and help.
After the patient return home, the stoma nurse works in conjunction with the GP and district nurses to ensure the patient are confident managing the stoma.
Stoma patients often have problems with the consistency and volume of their faeces. The output from an ileostomy peaks three to four hours after a main meal, often in the evenings. With a colostomy, the main output occurs in the morning after breakfast. Patients often find that they must restrict or change their diet to avoid excess wind, odour or loose stool. Eggs and fish often cause problems with bad smells, and fizzy drinks and beer produce excess wind and runny motions.
In general, the patient should try to eat a broad range of foods and use trial and error to find out which ones cause problems. It is important not to avoid dining out, because this is an important part of rehabilitation after stoma formation.
Wind is a particular problem to stoma patients who travel by air because the change in pressure in an aircraft cabin can cause large amounts of wind to be passed, which can even cause the stoma bag to come off. To prevent this, the patient must avoid fizzy drinks before and during flights, and make sure the patient use a stoma bag with a gas filter.
Another very important aspect of stoma care that will be discussed by the stoma nurse is skin care. The skin around the patientr stoma can become sore and broken if it is not cared for meticulously.
If the patient have an ileostomy the patient will need to take in more water and salt than normal, because these are no longer being reabsorbed in the large bowel. About an extra litre of water each day, and more in warm weather, is needed.
How can I manage a stoma?
Self-care action plan
A range of bags and seals are available that protect the skin surrounding the stoma site and discretely allow for collection and disposal of faeces. Appliances today use hypoallergenic protective skin barriers and creams, and soft, smell-proof bags to help the patientr mobility. The bags and seal appliances come in either one piece, which incorporate a protective skin barrier, or two pieces, with a separate protective barrier that remains on the skin between bag changes and needs to be changed every few days. The bags may be drainable (used especially with an ileostomy), or closed (used especially with a colostomy). Although their contents can be flushed down the toilet, the bags themselves cannot be disposed of this way.
Special filters are available for wind, special lotions and cleansing wipes for the skin around the stoma, cotton covers for the bag to improve the comfort of wearing it, and caps that block off the stoma for use in sports when patients have a regular stoma action. Other useful aids include travel mirrors and opaque disposal bags.
Medicines
Most patients with a stoma can control its output by changing their diet and do not need medication, but from time to time a little extra help may be required. The following drugs are sometimes used by patients with stomas:
- codeine phosphate slows down the passage of material through the gut and increases the amount of water absorbed, and hence more solid stools result
- kaolin and morphine are useful in bad cases of diarrhoea
- loperamide is also used in diarrhoea
- magnesium hydroxide helps relieve constipation in colostomy patients
- ispaghula husk is useful in helping colostomy patients who suffer with constipation, but because it increases water and salt loss, it should not be used by those with an ileostomy.
What is the outcome of a stoma?
The patient can expect to lead a normal, complication-free life after the patient have fully recovered from the stoma operation. Indeed, many people become much more active afterwards as their symptoms have been relieved. However, the patient should have an occasional medical check up with the patientr doctor to ensure the stoma remains in good condition.
Occasionally, an ileostomy or colostomy can prolapse (protrude) or become narrowed, so blocking the passage of faeces. Both of these problems can be corrected surgically.
Stoma patients often have problems with the consistency and volume of their faeces. The output from an ileostomy peaks three to four hours after a main meal, often in the evenings. With a colostomy, the main output occurs in the morning after breakfast. Patients often find that they must restrict or change their diet to avoid excess wind, odour or loose stool. Eggs and fish often cause problems with bad smells, and fizzy drinks and beer produce excess wind and runny motions.
